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Hemodialysis-induced bradycardia, "a plumbing issue": Resolved with catheter repositioning
Subhas Sitaula1, Pratibha Kaul1, Vikram Aggarwal2
1Department of Medicine, Division of Pulmonary and Critical Care, State University of New York (SUNY) Upstate Medical University, Syracuse, New York.
Insights
Sudden cardiac death in hemodialysis patients can be triggered by arrhythmias. A misplaced central venous catheter (CVC) irritated the heart, causing bradycardia, which resolved after repositioning the CVC.
Area of Science:
- Cardiology
- Nephrology
- Medical Devices
Background:
- Sudden cardiac death (SCD) is a primary cause of mortality in patients undergoing chronic hemodialysis.
- Arrhythmias are strongly implicated as a major contributing factor to SCD in this population.
- The specific triggers for life-threatening arrhythmias in hemodialysis patients remain incompletely understood.
Observation:
- A 72-year-old male on chronic hemodialysis via a central venous catheter (CVC) experienced cardiac arrest within 10 minutes of a dialysis session.
- The following day, the patient developed symptomatic bradycardia and lost consciousness during dialysis.
- Chest X-ray revealed the CVC tip was positioned abnormally, touching the superior vena cava (SVC) wall, potentially irritating the sinoatrial node.
Findings:
- Recurrent symptomatic intra-dialytic bradycardia was directly linked to the malposition of the CVC.
- Repositioning the CVC to an optimal location in the SVC successfully resolved the bradyarrhythmias.
- The patient tolerated subsequent dialysis sessions without any cardiac events after catheter repositioning.
Implications:
- Abnormal CVC tip placement can precipitate severe bradyarrhythmias in hemodialysis patients.
- This case highlights the critical importance of CVC positioning for patient safety during dialysis.
- Understanding such mechanisms may offer insights into preventing fatal arrhythmias in hemodialysis patients with CVCs.
Abstract:
Sudden cardiac death (SCD) is reported as leading cause of death in patients on chronic hemodialysis. Arrhythmias are proposed to be a major predisposing factor for SCD. However, triggers for potentially lethal arrhythmias are not well understood. Here we describe a case of 72-year-old man on chronic hemodialysis via permanent Central venous catheter (CVC) who was admitted for evaluation after unwitnessed fall. Within 10 minutes of his first routine dialysis session in the hospital, he had cardiac-arrest. He was successfully resuscitated within 3 minutes. The next day, fifteen minutes into the dialysis session, he had bradycardia with telemetry demonstrating long sinus pause and he lost consciousness. After few minutes of Advanced Cardiac Life Support (ACLS) he regained pulse and consciousness. Further review of the chest X-ray revealed the tip of CVC to be directly touching the distal Superior Vena Cava (SVC) wall. We felt the catheter tip may have migrated after the fall and now is irritating the Sinoatrial node and triggering bradyarrhythmia. Next day, the CVC was exchanged, and the tip was placed higher up in superior vena-cava. After repositioning, we started him on dialysis under intensive monitoring, and he tolerated well without any arrhythmia. Subsequent dialysis was uneventful. We describe a case of recurrent symptomatic intra-dialytic bradycardia due to abnormal positioning of CVC that resolved after the repositioning of the catheter. This case in addition to similar case in nondialysis settlings provides additional insights into mechanisms of fatal arrhythmias in hemodialysis patient having CVC.